Fiber Broadband Application

Click Here to Download Application

Siren Telephone Company: Applicant Name

Applicant Cell #

Driver's License (ID#)

State

DOB

FEIN #

Federal Employer Identification Number

Additional Applicant Name

Additional Applicant Cell #

Service Address

Street Address City State ZIP Code

Township

Mailing Address

Street Address City State ZIP Code

Preferred Email Address

Broadband Speeds

50 Mbps $73.55 per month

100 Mbps $114.70 per month

250 Mbps $153.70 per month

Higher Fiber Speeds Available Per Request (estimated prices, taxes & fees may vary)

$125.00 Installation Fee

Untitled

Static IP Address $10.00 per month (The following items may require a Static IP: Security Cameras & VPN’s)

Wireless Router Option

ZyXel Dual Band Router (WiFi6) onetime fee-$181.00 *No Remote Support

Adtran 834-5 Dual Band Wireless Router-onetime fee $191.00 *Remote Support Available

General wireless router programming fee, not purchased from Sirentel $32.00 onetime fee

Wireless Router w/App Based Setting, will require additional programming fee (depending on model).

Customer Has Own Wireless Router, Customer Will Program (No Charge)

*Router purchased from Sirentel has 1 year limited warranty. All prices subjected to change.

Wireless Router Password

(Must be 8 letters, no more than 12)

Name for Wireless Router

(or we will default to My Network)

Router Admin Password

(To secure your router settings)

I, the undersigned, am requesting a Siren Telephone Company’s Internet Account. By signing the agreement, I agree to the terms and conditions detailed in the policies found on Siren Telephone’s website, http://www.sirentel.com There is a monthly modem maintenance fee of $4.75, which covers the diagnosis, repair and/or replacement of the modem. Upon termination of Broadband service, the modem will stay at the location, unless requested by customer to be removed from premise. Broadband customer will be assessed a monthly charge on their statement. Broadband service is billed one month in advance. Install fees & first month of service is required before installation of service. Installation Fee $125.00 All above monthly prices are estimated (All prices subject to change). Broadband speeds may vary by location

Customer Signature

Date

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